MUSCULO SKELETAL

RADIOLOGY
oleh : dr.Dhanti Erma, SpRad
 Principles of Radiologic
Interpretation

 Technical Consideration
 Skeletal Anatomy and Physiology
 The Categorical approach to bone disease
 Radiologic predictor variables
 Medicolegal implication
 TECHNICAL CONSIDERATION

• Plain Film Radiography

•Contrast Examination
• Radionuclide Imaging
• Computed Tomography
• Magnetic Resonance Imaging
 SKELETAL ANATOMY AND
PHYSIOLOGY
Skeletal Development
•

Intramembranous Ossification
Enchondral Ossification
• Bone Structure
Epiphyse – Physis – ZPC – Metaphysis
Diaphysis
Cortex – Medulla – Periosteum
Endosteum
• Bone Metabolism
Bone mineral - Hormones
Anatomy
Anatomy
Anatomy
THE CATEGORICAL APPROACH TO
BONE DISEASE

• Congenital
• Infection
• Neoplasma
• Trauma
• Autoimun
RADIOLOGIC PREDICTOR VARIABLES

Preliminary Analysis
Clinical data
Number of lesions
Symetri of lesions
Determination of Systems Involved
RADIOLOGIC PREDICTOR VARIABLES

• Analysis of The Lesions

Skeletal Location
Position Within Bone
Site of Origin
Shape
Size
Margination
Cortical Integrity
RADIOLOGIC PREDICTOR VARIABLES

• Behavior of Lesions
Osteolytic Lesions
Osteoblastic Lesions
Mixed Lesions
• Matrix
• Periosteal Response
Solid Respons
Laminated Respons
Spiculated Respons
Codmans’ Triangle
RADIOLOGIC PREDICTOR VARIABLES

• Soft Tissue Changes

• Supplementary Analysis
Other imaging Procedures
Laboratory Examination
Biopsy
TRAUMA

Fracture and Dislocation

The radiographs should be made
• Include at least one joint
• Preferably two joints
• Two position AP – LAT
TRAUMA
Time intervals between Radiographic Study
• Initial Diagnostic study
• Post reduction and post immobilization
• One or Two weeks later, if position has
changed
• After approximately six eight weeks for
Primary callus
• After each plaster cast or traction change
• Before final discharge of patient
TRAUMA

Types of Fracture
• Closed fracture
Does not break the skin or communicate
with the outside environment
Simple fracture
• Open fractur
Penetrates the skin over fracture site
Compound fracture
TRAUMA
• Comminuted fracture
Two or more bony fragments have separated
• Non Comminuted fracture
Penetrates completely through the bone
• Avulsion fracture
Tearing away of a portion of the bone
• Impaction fracture
Bone is driven into its adjacent segmen
 TRAUMA
• Incomplete Fracture
Broken only one side of the bone
Greenstick (Hickory Stick) fracture
Torus (Buckling) fracture

Fracture Orientation
• Oblique fractur
Commonly occurs in the shaft of long
tubular bone
45° to the long axis of the bone
Fractur
Fracture
TRAUMA
• Spiral fractur
Torsion, coupled with axial compression
and angulation
• Transverse fractur
Run at a right angle to the lonh axis
Uncommon through healthy bone
Pathologic fractur
Fracture
TRAUMA

Spatial Relationships of Fracture

• Aligment
Position of the distal fragment in relation
to the proximal fragment
• Apposition
Closeness of the bony contact at the
fracture site
If the ends are pulled referred to as
Distraction
Fracture
TRAUMA
• Rotation
Twisting forces on a fractured bone along
its longitudinal axis
Traumatic Articular Lesions
• Subluxation
• Dislocation
• Diastasis
Epiphyseal Fractures
• Salter-Harris Classification
Salter - Harris
Dislocation
TRAUMA
Fracture Healing
• Main steps in fracture healing
Formation of hematoma
Organization of hematoma
Formation of fibrous callus
Replacement of fibrous callus by
primary bony callus
Absorption primary bony callus
Transformation to secondary bony callus
Remodeling
 TRAUMA

Complication of Fractures
• Immediate complication
Arterial injury
Compartement syndrome
Gas gangrene
Fat embolism syndrome
Thromboembolism
TRAUMA
 Intermediate complication
 Osteomyelitis
 Myositis ossificans
 Synostosis
 Delayed union

 Delayed complication
 Osteonecrosis
 Osteoporosis
 Non union – Mal union
Myositis Ossificans
INFECTION

Suppurative Osteomyelitis
• General Consideration
Systemic or Local infections
Immunosuppresed patients, alcoholics,
newborns, and drug addicts are
predisposed
Antibiotics have significatly reduced the
sepsis-related mortality
INFECTION

• Etiology
Staphylococcus aureus causes 90%
Pathway for the spread
Hematogenous
Contigunous
Direct Implantation
Postoperative
INFECTION

• Radiologic Features
Bone scan are the earliest means of
diagnosis
Radiographic latent period for plain film
10 days for extremities
21 days for spine
Soft tissue alteration : elevated fat planes,
obliterated fat planes, increased density.
INFECTION

Bone changes :

Moth-eaten bone destruction

Usually metaphyseal in origin
Periosteal new bone formation
Solid – Laminated – Codman’s Triangle
Sequestrum
Involucrum
Joint space destruction (ankylosis)
0steomyelitis
OSTEOMYELITIS
INFECTION

Septic Arthritis
• General consideration

Single joint involvment in the rule

Most common rute is hematogenous
or direct traumatic implantation
• Etiology
Most frequently is Staphylococcus Aureus
INFECTION

• Radiologic Features

The knee and hip are the most common

sites
Joint effusion leads to distrorsion of the
fat folds
Positive Waldenstorm’s sign
Rapid loss of joint space
Bony ankylosis
INFECTION

Nonsuppurative osteomyelitis
(tuberculosis)

• General Consideration

Found in patients such as prepubertal

children, debilitated geriatric, silicosis,
AIDS sufferers, Lymphoma patients,
Alcoholics, corticosteroid and drug abusers
INFECTION

• Etiology
Mycobacterium tuberculosis
Two mode of spread
Inhalation
Ingestion
INFECTION

• Radiologic Features

Spinal tuberculosis is most common at L-I

Early sign for spine are :
Lytic endplate destruction
loss of disc height
Anterior “ gouge defect “
Paraspinal swelling
INFECTION
Advanced sign for spinal involvement are:

Vertebral body collaps

Gibbus formation and obliteration of the disc
Tubercular arthritis is common in the hip and
knee
Uniform joint space narowing, early
destruction of the subchondral cortex, “moth-
eaten” bone destruction and juxtaarticular
osteoporosis are the cardinal sign of tubercular
arthritis
Tuberculosis
Tuberculosis
TUMORS AND TUMORLIKE
PROCESSES
METASTATIC BONE TUMORS
PRIMARY MALIGNANT BONE TUMORS

• Multiple myeloma
• Osteosarcoma
• Ewing’s Sarcoma

PRIMARY QUASIMALIGNANT BONE

TUMOR
• Giant Cell Tumor
TUMORS

PRIMARY BENIGN BONE TUMORS

• Osteochondroma
• Osteoma
• Bone island
• Osteoid osteoma
• Simple bone cyst
• Aneurysmal bone cyst
 TUMORS
Metastatic Bone Tumors
• General Consideration
The most common malignant tumors
CNS tumors and basal cell Ca rarely
Life threatening complication

• Insidence
70% are metastatic, 30% are primary
In females 70% from breast Ca
In males 60% from prostate Ca
TUMORS

• Radiologic Features

Technetium bone scan

80% of all metastase are located in the
central or axial skeleton
- Spine and Pelvis being a most common
Alteration in bone density and architecture
75% osteolytic, moth eaten or permeative
15% osteoblastic
Periosteal respose is rare
Metastatic
TUMORS

Primary Malignant Bone Tumors

• Multiple Myeloma
Bone scan are cold
Gross Osteoporosis may be the only early
sign
Punched out lesions
Vertebra plana or wrinkled vertebra
Preservation of pedicles
Multiple Myeloma
Multiple Myeloma
TUMORS

• Osteosarcoma
75% of cases occurs in the 10 to 25 age
Metaphyses of the distal femur, proximal
humerus are the most common sites
Permeative or ivory medulary lesion in
metaphysis of a long tubular bone
A sunburst or sunray periosteal response
Cortical disruption with soft tissue mass
formation
Sclerotic – Lytic – Mixed lesion
Osteosarcoma
Osteosarcoma
TUMORS
• Ewing’s Sarcoma
Most cases occur in the 10 – 25 age range
May mimic infection
Diaphyseal permeative lesion
Femur, tibia and fibula
Onion skin periosteal response
Most common primary malignant bone
tumor to metastasize to bone
Ewing’s Sarcoma
TUMORS

Primary quasimalignant bone tumor

• Giant cell Tumor
Osteoclastoma
20-40 years is the usual age range
Distal femur, proximal tibia
distal radius, proximal humerus
Metaphysis and extend to subarticular
Radiolucent, excentric
Soap Buble appearance
Giant Cell Tumor
TUMOR

Primary Benign Bone Tumors

• Osteochondroma
Painless and hard mass near a joint
Humerus, tibia, femur, ribs
Two types : - sessile
- pedunculated
Coat hanger exostose – cauliflower mass
The cortex and spongiosa blend
imperceptibly
Osteochondroma
TUMOR

• Osteoma
A rise in membranous bones
Sinuses – frontal, ethmoid
Mandible
Skull bones
Homogenously opaque
 Osteoma


TUMOR
• Bone Island
Epiphyseal, metaphyseal
Medulary
Round – oval : Long axis oriented
Smooth or radiating border
Opaque
Normal adjecent cortex
May change size
TUMOR

• Osteoid osteoma
Consists a nidus, thst usually 1 cm or less
Target calsification
Most common location is in the cortex
Radiolucent nidus surrounded by perifocal
reactive sclerosis
Osteoid Osteoma
TUMOR
• Simple Bone Cyst
Expansile radiolucent
Proximal humerus, femur, calcaneus
No periosteal reaction
Pathologic fracture
• Aneurysmal Bone Cyst
Some lesion may reach 8 – 10 cm
Cortical ballooning “ blown out app”
Aneurysmal Bone Cyst
Aneurysmal Bone Cyst
ARTHRITIC DISORDERS

Degenerative Disorders

Degenerative Joint Disease

etc
Inflamatory Disorders
Rheumatoid Arthritis
etc
Metabolic Disorders
Gout
etc
ARTHRITIC
• Degenerative Joint Disease
Osteoarthritis – Osteoarthrosis
Asimetric distribution
Non uniform loss of the joint space
Osteophytes
Subchondral sclerosis
Subchondral cyst
Loose bodies
Subluxation
Osteoarthrosis
ARTHRITIC
• Rheumatoid Arthritis
Generalized Connective tissue disorder
Higest insidence among the 40 – 50 year
Symetric peripheral joint pain and swelling
Early : - Soft tissue swelling
Marginal erosions
Osteoporosis - Periostitis
Loss of joint space
Late : - Ankylosis
Deformities
Rheumatoid Arthritis
Rheumatoid Arthritis
ARTHRITIC

•Gout

Disorder of purin metabolism

Deposite of Sodium monourate crystals
into cartilage, synovium, periarticular
and subcutaneous tissues
Dense soft tissue Tophi, preservation
of joint space, Bone erosions (marginal
periarticular) “overhanging margin sign”
Metatarsophalangeal joint
Gout